Demographics and epidemiology of pancreatic cancer. Cancer J. 2012;18:477-484. [PMID: 23187833 DOI: 10.1097/ppo.0b013e3182756803]

Pancreatic cancer and exosomes: role in progression, diagnosis, monitoring, and treatment

Pancreatic cancer (PC) is one of the most dangerous diseases that threaten human life, and investigating the details affecting its progression or regression is particularly important. Exosomes are one of the derivatives produced from different cells, including tumor cells and other cells such as Tregs, M2 macrophages, and MDSCs, and can help tumor growth. These exosomes perform their actions by affecting the cells in the tumor microenvironment, such as pancreatic stellate cells (PSCs) that produce extracellular matrix (ECM) components and immune cells that are responsible for killing tumor cells. It has also been shown that pancreatic cancer cell (PCC)-derived exosomes at different stages carry molecules. Checking the presence of these molecules in the blood and other body fluids can help us in the early stage diagnosis and monitoring of PC. However, immune system cell-derived exosomes (IEXs) and mesenchymal stem cell (MSC)-derived exosomes can contribute to PC treatment. Immune cells produce exosomes as part of the mechanisms involved in the immune surveillance and tumor cell-killing phenomenon. Exosomes can be modified in such a way that their antitumor properties are enhanced. One of these methods is drug loading in exosomes, which can significantly increase the effectiveness of chemotherapy drugs. In general, exosomes form a complex intercellular communication network that plays a role in developing, progressing, diagnosing, monitoring, and treating pancreatic cancer.

Smoking and Pancreatic Cancer: Smoking Patterns, Tobacco Type, and Dose-Response Relationship

Pancreatic cancer (PC) is the primary cause of cancer death in the United States and Europe. Despite remarkable advances in the molecular understanding of PC and advances in new therapeutic approaches, PC remains a disease with a poor prognosis. Although evidence indicates that long-term smoking is a major cause of PC, the molecular pathways behind smoking-induced PC pathogenesis are not fully understood. Smoking cessation can significantly reduce the occurrence of PC.

This review explores the processes underpinning the influence of smoking-related chemicals on fibrosis and inflammation and provides insight into the etiology of PC. In the future, a thorough exploration of the effects of smoking chemicals on the activity of pancreatic stem cells and then on the essential mediators of the association with cancer cells would likely yield new diagnostic targets.

Sustained Weight Loss, Weight Cycling, and Weight Gain During Adulthood and Pancreatic Cancer Incidence in the Women's Health Initiative

Pancreatic cancer (PC) is the fourth leading cause of cancer mortality among women in the United States. Obesity is positively associated with PC risk. Current health recommendations focus on weight maintenance for healthy-weight individuals and weight loss for overweight/obese individuals; however, little research has assessed associations between PC risk and changes in weight throughout the life course. Using prospective cohort study data, we examined the relationship between baseline adulthood weight patterns self-reported between 1993 and 1998 and PC risk in 136,834 postmenopausal women with 873 incident PC cases through September 30, 2015, in the Women's Health Initiative. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using Cox proportional hazards models, adjusting for age, smoking habits, heavy alcohol consumption, and body mass index. Compared with women with stable weight, no significant associations were found between steady weight gain (HR = 1.01, 95% CI: 0.83, 1.22), sustained weight loss (HR = 1.26, 95% CI: 0.85, 1.87), or weight cycling patterns (HR = 1.08, 95% CI: 0.89, 1.30) and PC. Results were similar when the outcome definition was restricted to pancreatic adenocarcinoma cases. Overall, we did not find evidence to suggest that weight changes in adulthood significantly impact PC risk among postmenopausal women.

Role of targeted immunotherapy for pancreatic ductal adenocarcinoma (PDAC) treatment: An overview

Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest solid tumors with a high mortality rate and poor survival rate. Depending on the tumor stage, PDAC is either treated by resection surgery, chemotherapies, or radiotherapies. Various chemotherapeutic agents have been used to treat PDAC, alone or in combination. Despite the combinations, chemotherapy exhibits many side-effects leading to an increase in the toxicity profile amongst the PDAC patients. Additionally, these standard chemotherapeutic agents have only a modest impact on patient survival due to their limited efficacy. PDAC was previously considered as an immunologically silent malignancy, but recent findings have demonstrated that effective immune-mediated tumor cell death can be used for its treatment. PDAC is characterized by an immunosuppressive tumor microenvironment accompanied by the major expression of myeloid-derived suppressor cells (MDSC) and M2 tumor-associated macrophages. In contrast, the expression of CD8⁺ T cells is significantly low. Additionally, infiltration of mast cells in PDAC correlates with the poor prognosis. Immunotherapeutic agents target the immunity mediators and empower them to suppress the tumor and effectively treat PDAC. Different targets are studied and exploited to induce an antitumor immune response in PDAC patients. In recent times, site-specific delivery of immunotherapeutics also gained attention among researchers to effectively treat PDAC. In the present review, existing immunotherapies for PDAC treatment along with their limitations are addressed in detail. The review also includes the pathophysiology, traditional strategies and significance of targeted immunotherapies to combat PDAC effectively. Separately, the identification of ideal targets for the targeted therapy of PDAC is also reviewed exhaustively. Additionally, the review also addresses the applications of targeted immunotherapeutics like checkpoint inhibitors, adoptive T-cell therapy etc.

Time-frequency analysis of serum with proton nuclear magnetic resonance for diagnosis of pancreatic cancer

Although serum markers such as carcinoembryonic antigen (CEA) and carbohydrate antigen (CA19-9) have been widely used in screening for pancreatic cancer (PC), their sensitivity and specificity are unsatisfactory. Recently, a novel tool of analyzing serum using the short-time Fourier transform (STFT) of free induction decays (FIDs) obtained by ¹H-NMR has been introduced. We for the first time evaluated the utility of this technology as a diagnostic tool for PC. Serum was obtained from PC patients before starting any treatments. Samples taken from individuals with benign diseases or donors for liver transplantation were obtained as controls. Serum samples from both groups underwent ¹H-NMR and STFT of FIDs. STFT data were analyzed by partial least squares discriminant analysis (PLS-DA) to clarify whether differences were apparent between groups. As a result, PLS-DA score plots indicated that STFT of FIDs enabled effective classification of groups with and without PC. Additionally, in a subgroup of PC, long-term survivors (≥ 2 years) could be discriminated from short-term survivors (< 2 years), regardless of pathologic stage or CEA or CA19-9 levels. In conclusion, STFT of FIDs obtained from ¹H-NMR have a potential to be a diagnostic and prognostic tool of PC.

The Impact of Cirrhosis on Pancreatic Cancer Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Cirrhosis has been considered a contraindication to major abdominal surgeries, due to increased risk for postoperative morbidity and mortality. The aim of this study was to assess the safety of pancreatectomy in cirrhotic versus non-cirrhotic patients.

METHODS

The present systematic review and meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. All meta-analyses were performed using the random effects model.

RESULTS

Eight studies were eventually included, enrolling 1229 patients (cirrhotics: 722; and Child-Pugh A: 593; Child-Pugh B/C: 129) who underwent surgery for pancreatic cancer. The overall postoperative morbidity rate was 66% (51%-80%). Infections (26%) and ascites formation/worsening (23%) were the most common postoperative complications, followed by anastomotic leak/fistula (17%). Non-cirrhotic patients were less likely to suffer from anastomotic leak/fistula (OR: 0.39; 95% CI: 0.23-0.65) and infections (OR: 0.41; 95% CI: 0.25-0.67). Postoperative mortality rate was statistically significantly lower in non-cirrhotic versus cirrhotic patients (OR: 0.18; 95% CI:0.18-0.39). The odds ratios of 1 year (OR: 0.62; 95% CI: 0.30-1.30), 2 year (OR: 0.67; 95% CI: 0.25-1.83) and 3 year all-cause mortality (OR: 0.32; 95% CI: 20.03-2.99) were not significantly different between cirrhotic versus non-cirrhotic patients.

CONCLUSION

This study demonstrated that non-cirrhotic patients were less likely to undergo any type of re-intervention and had statistically significant lower postoperative mortality rates compared to patients with cirrhosis.

Pancreaticoduodenectomy in a low-resection volume region: a population-level study examining the impact of hospital-volume on surgical quality and longer-term survival

BACKGROUND

An association between higher hospital-volume and better "quality of surgery" and long-term survival has not been reported following pancreatic cancer surgery in low resection-volume regions such as in Australia. Using a population-level study, we compare "quality of surgery" and two-year survival following pancreaticoduodenectomy between Australian hospitals grouped by resection-volume.

METHODS

Data on all patients undergoing pancreaticoduodenectomy for adenocarcinoma in the Australian state of Queensland, between 2001 and 2015, were obtained from the Queensland Oncology Repository. Hospitals were grouped into high (≥6 resections annually) and low (<6) volume centres. Following adjustment for case-mix, "quality-of-treatment" indicators were compared between hospital groups using multivariate logistic regression and Poisson regression analysis; and two-year cancer-specific and overall survival were compared using multivariate Cox proportional hazard models.

RESULTS

Compared with high-volume centres, low-volume centres had worse two-year cancer-specific survival (Adjusted HR = 1.31; 95% CI:1.03-1.68), higher 30-day mortality (Adjusted IRR = 3.81; 95% CI: 1.36-10.62) and fewer patients received "high-quality surgery" (Adjusted OR = 0.55; 95% CI: 0.33-0.90). Differences in 30-day mortality, or "quality-of-treatment" indicators did not entirely explain the observed survival difference between hospital-volume groups.

CONCLUSION

In an Australian environment, a "high" hospital-volume was significantly associated with better quality surgery and two-year survival following pancreaticoduodenectomy.

Pilot study on longitudinal change in pancreatic proton density fat fraction during a weight-loss surgery program in adults with obesity

BACKGROUND

Quantitative-chemical-shift-encoded (CSE)-MRI methods have been applied to the liver. The feasibility and potential utility CSE-MRI in monitoring changes in pancreatic proton density fat fraction (PDFF) have not yet been demonstrated.

PURPOSE

To use quantitative CSE-MRI to estimate pancreatic fat changes during a weight-loss program in adults with severe obesity and nonalcoholic fatty liver disease (NAFLD). To explore the relationship of reduction in pancreatic PDFF with reductions in anthropometric indices.

STUDY TYPE

Prospective/longitudinal.

POPULATION

Nine adults with severe obesity and NAFLD enrolled in a weight-loss program.

FIELD STRENGTH/SEQUENCE

CSE-MRI fat quantification techniques and multistation-volumetric fat/water separation techniques were performed at 3 T.

ASSESSMENT

PDFF values were recorded from parametric maps colocalized across timepoints.

STATISTICAL TESTS

Rates of change of log-transformed variables across time were determined (linear-regression), and their significance assessed compared with no change (Wilcoxon test). Rates of change were correlated pairwise (Spearman's correlation).

RESULTS

Mean pancreatic PDFF decreased by 5.7% (range 0.7-17.7%) from 14.3 to 8.6%, hepatic PDFF by 11.4% (2.6-22.0%) from 14.8 to 3.4%, weight by 30.9 kg (17.3-64.2 kg) from 119.0 to 88.1 kg, body mass index by 11.0 kg/m2 (6.3-19.1 kg/m2 ) from 44.1 to 32.9 kg/m2 , waist circumference (WC) by 25.2 cm (4.0-41.0 cm) from 133.1 to 107.9 cm, HC by 23.5 cm (4.5-47.0 cm) from 135.8 to 112.3 cm, visceral adipose tissue (VAT) by 2.9 L (1.7-5.7 L) from 7.1 to 4.2 L, subcutaneous adipose tissue (SCAT) by 4.0 L (2.9-7.4 L) from 15.0 to 11.0 L. Log-transformed rate of change for pancreatic PDFF was moderately correlated with log-transformed rates for hepatic PDFF, VAT, SCAT, and WC (ρ = 0.5, 0.47, 0.45, and 0.48, respectively), although not statistically significant.

DATA CONCLUSION

Changes in pancreatic PDFF can be estimated by quantitative CSE-MRI in adults undergoing a weight-loss surgery program. Pancreatic and hepatic PDFF and anthropometric indices decreased significantly.

LEVEL OF EVIDENCE

2 Technical Efficacy Stage: 1 J. Magn. Reson. Imaging 2019;50:1092-1102.

Long noncoding RNA TP53TG1 promotes pancreatic ductal adenocarcinoma development by acting as a molecular sponge of microRNA-96

Long noncoding RNAs (lncRNAs) are emerging as key regulators in cancer initiation and progression. TP53TG1 is a recently identified lncRNA and several studies have shown that TP53TG1 may play the role of tumor suppressor gene or oncogene in different tumors. Nevertheless, the involvement of TP53TG1 in carcinogenesis of pancreatic ductal adenocarcinoma (PDAC) has not been characterized. In our studies, we identified that TP53TG1 was highly expressed in PDAC and was a novel regulator of PDAC development. Knockdown of TP53TG1 inhibited proliferation, induced apoptosis, and decreased migration and invasion in PDAC cells, whereas enhanced expression of TP53TG1 had the opposite effects. Mechanistically, TP53TG1 could directly bind to microRNA (miR)-96 and effectively function as a sponge for miR-96, thus antagonizing the functions of miR-96 and leading to derepression of its endogenous target KRAS, which is a core oncogene in the initiation and maintenance of PDAC. Taken together, these observations imply that TP53TG1 contributes to the growth and progression of PDAC by acting as a competing endogenous RNA (ceRNA) to competitively bind to miR-96 and regulate KRAS expression, which highlights the importance of the complicated miRNA-lncRNA network in modulating the progression of PDAC.

Potato consumption and risk of pancreatic cancer in the HELGA cohort

Potatoes have been a staple food in many countries throughout the years. Potatoes have a high glycaemic index (GI) score, and high GI has been associated with several chronic diseases and cancers. Still, the research on potatoes and health is scarce and contradictive, and we identified no prospective studies that had investigated the association between potatoes as a single food and the risk of pancreatic cancer. The aim of this study was to prospectively investigate the association between potato consumption and pancreatic cancer among 114 240 men and women in the prospective HELGA cohort, using Cox proportional hazard models. Information on diet (validated FFQ’s), lifestyle and health was collected by means of a questionnaire, and 221 pancreatic cancer cases were identified through cancer registries. The mean follow-up time was 11·4 (95 % CI 0·3, 16·9) years. High consumption of potatoes showed a non-significantly higher risk of pancreatic cancer in the adjusted model (hazard ratio (HR) 1·44; 95 % CI 0·93, 2·22, P_{for trend} 0·030) when comparing the highest v. the lowest quartile of potato consumption. In the sex-specific analyses, significant associations were found for females (HR 2·00; 95 % CI 1·07, 3·72, P_{for trend} 0·020), but not for males (HR 1·01; 95 % CI 0·56, 1·84, P_{for trend} 0·34). In addition, we explored the associations by spline regression, and the absence of dose–response effects was confirmed. In this study, high potato consumption was not consistently associated with a higher risk of pancreatic cancer. Further studies with larger populations are needed to explore the possible sex difference.

Unchanged mortality in patients with acute cholangitis despite an increase in malignant etiologies - a 25-year epidemiological study

Background and aims: Acute cholangitis (AC) is a rare but serious condition, with an incidence of 7.0 per 10,000 people and mortality rates up to 10%. The aim of this study was to describe changes in obstruction etiology, comorbidities, clinical factors, and mortality among AC patients during a 25-year period. Methods: Using a database of 11,563 consecutive ERCP-procedures performed from 1990-2015 at Odense University Hospital, we identified all AC cases during that period. Clinical and epidemiological data were collected from the database and the Danish Patient Registry. Association with 30-day mortality was investigated using multiple logistic regression analysis with adjustment for confounding factors. Results: In total, 775 consecutive and individual cases of AC were included. Among cases, 42% (n = 326) were of malignant etiology, with an increasing incidence over time (regression coefficient [95% CI]: 0.03 [0.01-0.04] per year; p = .01). Mean Charlson Comorbidity Index was 1.4, with an increase over time (regression coefficient [95% CI]: 0.04 [0.03-0.05] per year; p < .01). Malignant obstruction etiology was associated with 30-day mortality (OR [95% CI]: 1.11 [1.04-1.18]; p < .01). Overall 30-day mortality was 12% (n = 91). After adjustment for confounding factors, no significant changes in 30-day mortality were observed over time (OR [95% CI]: 1 [1-1.00]; p = .91 per year). Conclusion: Significant increases in the incidence of malignant obstruction etiology and severity of comorbidities among AC patients were observed during the study period. Despite those findings, 30-day mortality remained unchanged, potentially reflecting a general improvement in the management of AC.

Pancreatic cancer subtypes: a roadmap for precision medicine

Pancreatic ductal adenocarcinoma (PDAC) is projected to become the second cause of cancer-related deaths by 2020. Although it has traditionally been approached as a disease, accumulated evidences point to the clinical heterogeneity of this disease, which translate into disparity in outcomes among the patients. Much emphasis has been put into patient classification introducing a platform for more tailored therapies. In the last 10 years, there have been important advances in the understanding of the molecular pathogenesis of PDAC, which has culminated with a comprehensive integrated genomic analysis from RNA expression profiles. Bailey et al. defined four subtypes and the different transcriptional networks underlying them. Firstly, we briefly describe and compare different subtyping approaches, which are mostly based on tissue mRNA expression analysis. We propose that these latest approaches to disease classification embrace not only those patients that are surgically resectable (20%), but even patients ineligible for surgery. Such considerations will include possible reclassification of these specific subtypes, enabling more personalized diagnosis and individualized treatment. The ultimate goal of this review is to identify current challenges in this area and summarize current efforts in developing clinical modalities that can effectively identify these subtypes in order to advance Precision Medicine. KEY MESSAGES   • Pancreatic cancer can no longer be considered as one disease.   • The heterogeneity underlying pancreatic cancer patients makes therapeutic options based on one-size-fits-all approach ineffective.   • Identifying patients that could benefit from a specific treatment would help to avoid futile therapy approaches and to improve outcomes and quality of life of those whose long-term survival is unpromising.

Rates of exposure to environmental tobacco smoke from various indoor environments among US children and nonsmoker adolescents and adults

Data from National Health and Nutrition Examination Survey for 2013-2014 were used to compute rates of exposure (ROE) to environmental tobacco smoke (ETS) from various indoor environments among US children and nonsmoking adolescents and adults. In a typical week in USA, 473,000 infants (ROE, 11%), 3.36 million children aged 1-5 years (ROE, 16.4%), and 4.59 million children aged 6-11 years (ROE, 18.6%) are exposed to ETS from indoor environments only. ROE among children was found to be highest by inhaling tobacco smoke inside home, riding in a car, and when visiting other people's homes. In a typical week, 4.1 million nonsmoking adolescents (ROE, 29.2%) were being exposed to ETS. For every one adolescent smoker, 2.4 nonsmoker adolescents were being subjected to ETS exposure. Both non-Hispanic White (NHW) and non-Hispanic Black (NHB) nonsmoking adolescents had higher ROE (p < 0.01) than Hispanics (HISP) and non-Hispanic Asians (NHAS). Also, in a typical week, 16.8 million nonsmoking adults (ROE, 29.2%) were being exposed to ETS. For every adult smoker, 0.7 nonsmoker adult was subjected to ETS exposure. Both NHW and NHB nonsmoking adults had higher ROE (p < 0.01) than HISP and NHAS and males had higher ROE than females (p < 0.01).

A novel scoring system to analyze combined effect of lifestyle factors on pancreatic cancer risk: a retrospective case-control study

Although several risk factors for the onset of pancreatic ductal adenocarcinoma (PDAC) have been identified, currently, no scoring system to systemically evaluate the risk of PDAC has been established. In this study, we aimed to use a population of over 1200 patients to build a novel scoring system, and evaluated combined effects of risk factors for PDAC patients.A set of 4904 participants including 1274 PDAC patients and 3630 non-cancer individuals were recruited for the single-center study over 17-year period (1997~2013). Systematic logical analysis were presented for case and control groups, and a risk rating system was constructed to assess combined risk factors. Seven independent risk factors were identified with the increased risk of PDAC, were selected into the risk score. A merged risk assessment model was established, demonstrating significantly increased PDAC risk in following a number of rising scores. Individuals with scores from 1 to more than 4, the responding OR (95% CI) were 3.06 (2.57~3.65), 7.08 (5.63~8.91), 22.4 (14.2~35.4), and 31.4 (12.7~77.5), respectively. The integer-based risk score in the study can be used for risk stratification to accurately evaluate PDAC occurrence at an early stage. This scoring system provides an accurate risk assessment of PDAC risk.

Gut microbial profile analysis by MiSeq sequencing of pancreatic carcinoma patients in China

Pancreatic carcinoma (PC) is a lethal cancer. Gut microbiota is associated with some risk factors of PC, e.g. obesity and types II diabetes. However, the specific gut microbial profile in clinical PC in China has never been reported. This prospective study collected 85 PC and 57 matched healthy controls (HC) to analyze microbial characteristics by MiSeq sequencing. The results showed that gut microbial diversity was decreased in PC with an unique microbial profile, which partly attributed to its decrease of alpha diversity. Microbial alterations in PC featured by the increase of certain pathogens and lipopolysaccharides-producing bacteria, and the decrease of probiotics and butyrate-producing bacteria. Microbial community in obstruction cases was separated from the un-obstructed cases. Streptococcus was associated with the bile. Furthermore, 23 microbial functions e.g. Leucine and LPS biosynthesis were enriched, while 13 functions were reduced in PC. Importantly, based on 40 genera associated with PC, microbial markers achieves a high classification power with AUC of 0.842. In conclusion, gut microbial profile was unique in PC, providing a microbial marker for non-invasive PC diagnosis.

Menstrual and Reproductive Factors and Risk of Pancreatic Cancer in Women

BACKGROUND

Pancreatic cancer (PC) is a deadly disease with a 5-year survival of less than 5%. Worldwide PC incidence rates are lower among women than men. While this suggests a protective role for steroid hormones in PC risk, results from epidemiological studies are not consistent.

METHODS

153 new incident PC cases and 202 controls were recruited from a prospective case–control study, running in a referral center for endoscopic ultrasonography during 2011-2017. A structured valid and reliable questionnaire was used for data collection by a few trained interviewers. Odds ratios and 95% confidence intervals for reproductive factors and PC were estimated using logistic regression methods.

RESULTS

Mean age (SD) of the cases and the controls were 63.18 (11.4) and 63.37 (12.0) years, respectively. Age at menarche, age at menopause, number of parity, gravidity, and abortion were not associated with PC risk.

CONCLUSION

This study does not support the hypothesis that menstrual and reproductive factors are associated with PC risk.

Cancer Manipulation of Host Physiology: Lessons from Pancreatic Cancer

Homeostasis is a fundamental property of living organisms enabling the human body to withstand internal and external insults. In several chronic diseases, and especially in cancer, many homeostatic mechanisms are deranged. Pancreatic cancer in particular is notorious for its ability to invoke an intense fibroinflammatory stromal reaction facilitating its progression and resistance to treatment. In the past decade, several seminal discoveries have elucidated previously unrecognized modes of commandeering the host's defense systems. Here we review novel discoveries in pancreatic cancer immunobiology and attempt to integrate the notion of deranged homeostasis in the pathogenesis of this disease. We also highlight areas of controversy and obstacles that need to be overcome, hoping to further our mechanistic insight into this malignancy.

Sparse Proteomics Analysis - a compressed sensing-based approach for feature selection and classification of high-dimensional proteomics mass spectrometry data

BACKGROUND

High-throughput proteomics techniques, such as mass spectrometry (MS)-based approaches, produce very high-dimensional data-sets. In a clinical setting one is often interested in how mass spectra differ between patients of different classes, for example spectra from healthy patients vs. spectra from patients having a particular disease. Machine learning algorithms are needed to (a) identify these discriminating features and (b) classify unknown spectra based on this feature set. Since the acquired data is usually noisy, the algorithms should be robust against noise and outliers, while the identified feature set should be as small as possible.

RESULTS

We present a new algorithm, Sparse Proteomics Analysis (SPA), based on the theory of compressed sensing that allows us to identify a minimal discriminating set of features from mass spectrometry data-sets. We show (1) how our method performs on artificial and real-world data-sets, (2) that its performance is competitive with standard (and widely used) algorithms for analyzing proteomics data, and (3) that it is robust against random and systematic noise. We further demonstrate the applicability of our algorithm to two previously published clinical data-sets.

Nonsteroidal anti-inflammatory drugs, statins, and pancreatic cancer risk: a population-based case-control study

PURPOSE

Studies suggest that aspirin, other nonsteroidal anti-inflammatory drugs (NSAIDs), and statins may reduce risk of some cancers. However, findings have been conflicting as to whether these agents reduce the risk of pancreatic cancer.

METHODS

We used data from the Queensland Pancreatic Cancer Study, a population-based case-control study. In total, 704 cases and 711 age- and sex-matched controls were recruited. Participants completed an interview in which they were asked about history of NSAID and statin use. We included 522 cases and 653 controls who had completed the medication section of the interview in this analysis. Unconditional multivariable logistic regression was used to estimate associations between medication use and pancreatic cancer.

RESULTS

We found no consistent evidence of an association between use of NSAIDs or statins and risk of pancreatic cancer. There was some suggestion of a protective effect in infrequent users of selective COX-2 inhibitors, but no association in more frequent users. We did not find evidence of protective effects in analyses stratified by sex, smoking status, time between diagnosis and interview, or presence/absence of metastases.

CONCLUSIONS

Overall, our results do support the hypothesis that use of NSAIDs or statins may reduce the odds of developing pancreatic cancer.

Palliation With Endoscopic Metal Stents May Be Preferable to Surgical Intervention for Patients With Obstructive Pancreatic Head Adenocarcinoma

The aim of this study was to evaluate the efficacy of endoscopically placed metal stents in comparison with operative procedures, in patients with obstructive pancreatic head cancer. Endoscopic stenting techniques and materials for gastrointestinal malignancies are constantly improving. Despite this evolution, many still consider operative procedures to be the gold standard for palliation in patients with unresectable obstructive pancreatic head cancer. This is a retrospective study of 52 patients who were diagnosed with obstructive (biliary, duodenal, or both) adenocarcinoma of the pancreatic head. Twenty-nine patients (endoscopy group) underwent endoscopic stenting. Eleven patients (bypass group) underwent biliodigestive bypass. Twelve patients (Whipple group) underwent Whipple operation with curative intent; however, histopathology revealed R1 resection (palliative Whipple). T4 disease was identified in 13 (44.8%), 7 (63.6%), and 3 (25%) patients in the endoscopy, bypass, and Whipple groups, respectively. Metastatic disease was present only in the endoscopy group (n = 12; 41.3%). There was no intervention-related mortality. Median survival was 280 days [95% confidence interval (95% CI), 103, 456 days], 157 days (95% CI, 0, 411 days), and 647 days (95% CI, 300, 993 days) for the endoscopy, bypass, and Whipple groups, respectively (P = 0.111). In patients with obstructive pancreatic head cancer, endoscopic stenting may offer equally good palliation compared with surgical double bypass. The numerically (not statistically) better survival after palliative Whipple might be explained by the smaller tumor burden in this subgroup of patients and not by the superior efficacy of this operation.

Menstrual and Reproductive Factors, Hormone Use, and Risk of Pancreatic Cancer: Analysis From the International Pancreatic Cancer Case-Control Consortium (PanC4)

OBJECTIVES

We aimed to evaluate the relation between menstrual and reproductive factors, exogenous hormones, and risk of pancreatic cancer (PC).

METHODS

Eleven case-control studies within the International Pancreatic Cancer Case-control Consortium took part in the present study, including in total 2838 case and 4748 control women. Pooled estimates of odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated using a 2-step logistic regression model and adjusting for relevant covariates.

RESULTS

An inverse OR was observed in women who reported having had hysterectomy (ORyesvs.no, 0.78; 95% CI, 0.67-0.91), remaining significant in postmenopausal women and never-smoking women, adjusted for potential PC confounders. A mutually adjusted model with the joint effect for hormone replacement therapy (HRT) and hysterectomy showed significant inverse associations with PC in women who reported having had hysterectomy with HRT use (OR, 0.64; 95% CI, 0.48-0.84).

CONCLUSIONS

Our large pooled analysis suggests that women who have had a hysterectomy may have reduced risk of PC. However, we cannot rule out that the reduced risk could be due to factors or indications for having had a hysterectomy. Further investigation of risk according to HRT use and reason for hysterectomy may be necessary.

Association between family cancer history and risk of pancreatic cancer

PURPOSE

Family history of pancreatic adenocarcinoma is an established risk factor for the disease. However, associations of pancreatic cancer with other familial cancers are less clear. We analyzed data from the Queensland Pancreatic Cancer Study (QPCS), an Australian population-based case-control study, to investigate associations between family history of various cancer types and risk of pancreatic cancer.

MATERIALS AND METHODS

Our study included 591 pancreatic cancer patients and 646 controls, all of whom self-reported the histories of cancer in their first-degree relatives. We used logistic regression to estimate adjusted odds ratios (ORs) and their 95% confidence intervals (CIs). Based on our results, we conducted a systematic literature review using the Medline (OVID) database to identify articles pertaining to the association between family history of melanoma and risk of pancreatic cancer. A meta-analysis including associations in five published studies, unpublished results from a study co-author and the QPCS results was then performed using the DerSimonian and Laird random-effects model.

RESULTS

Cases were more likely than controls to report a family history of pancreatic cancer (OR 2.20, 95% CI 1.16-4.19) and melanoma (OR 1.74, 95% CI 1.03-2.95), but not of breast, ovarian, respiratory, other gastrointestinal or prostate cancer. Meta-analysis of melanoma family history and pancreatic cancer risk yielded an OR of 1.22 (95% CI 1.00-1.51).

CONCLUSIONS

Our results yield further evidence of increased risk of pancreatic cancer in those with family histories of the disease. We also provide suggestive evidence of an association between family history of melanoma and risk of pancreatic cancer.

Monocarboxylate Transporters MCT1 and MCT4 Regulate Migration and Invasion of Pancreatic Ductal Adenocarcinoma Cells

OBJECTIVES

Novel treatments for pancreatic ductal adenocarcinoma (PDAC) are severely needed. The aim of this work was to explore the roles of H-lactate monocarboxylate transporters 1 and 4 (MCT1 and MCT4) in PDAC cell migration and invasiveness.

METHODS

Monocarboxylate transporter expression, localization, activity, and function were explored in human PDAC cells (MIAPaCa-2, Panc-1, BxPC-3, AsPC-1) and normal human pancreatic ductal epithelial (HPDE) cells, by quantitative polymerase chain reaction, immunoblotting, immunocytochemistry, lactate flux, migration, and invasion assays.

RESULTS

MCT1 and MCT4 (messenger RNA, protein) were robustly expressed in all PDAC lines, localizing to the plasma membrane. Lactate influx capacity was highest in AsPC-1 cells and lowest in HPDE cells and was inhibited by the MCT inhibitor α-cyano-4-hydroxycinnamate (4-CIN), MCT1/MCT2 inhibitor AR-C155858, or knockdown of MCT1 or MCT4. PDAC cell migration was largely unaffected by MCT1/MCT2 inhibition or MCT1 knockdown but was reduced by 4-CIN and by MCT4 knockdown (BxPC-3). Invasion measured in Boyden chamber (BxPC-3, Panc-1) and spheroid outgrowth (BxPC-3) assays was attenuated by 4-CIN and AR-C155858 and by MCT1 or MCT4 knockdown.

CONCLUSIONS

Human PDAC cells exhibit robust MCT1 and MCT4 expression and partially MCT1- and MCT4-dependent lactate flux. PDAC cell migration is partially dependent on MCT4; and invasion, on MCT1 and MCT4. Inhibition of MCT1 and MCT4 may have clinical relevance in PDAC.

Adherence to World Cancer Research Fund/American Institute for Cancer Research recommendations and pancreatic cancer risk

BACKGROUND

Pancreatic cancer is a leading cause of cancer death. A role of dietary factors in pancreatic carcinogenesis has been suggested. The World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR) published 8 recommendations for cancer prevention. We evaluated the effect of adherence to the WCRF/AICR recommendations on pancreatic cancer risk.

METHODS

We operationalized 7 of the 8 WCRF/AICR recommendations to generate a WCRF/AICR score. We examined the association of WCRF/AICR score with pancreatic cancer in data from an Italian case-control study of 326 incident cases and 652 controls.

RESULTS

Adherence to WCRF/AICR recommendations was associated with a significantly decreased risk of pancreatic cancer. Using a WCRF/AICR score <3.5 as a reference, the adjusted odds ratio (OR) for a score 3.5-<4 was 0.80 (95% CI 0.49, 1.28), for a score 4-<5 0.54 (95% CI 0.35, 0.82), and for score 5 or more 0.41 (95% CI 0.24, 0.68; p-value for trend 0.0002). The OR for a continuous increment of one unit of the WCRF/AICR score was 0.72 (95% CI 0.60, 0.87).

CONCLUSION

Adherence to the WCRF/AICR recommendations may reduce pancreatic cancer risk.

Exposure to second hand smoke at home and work among nonsmokers

Exposure to second hand smoke (SHS) is associated with adverse health effects. This study was undertaken to assess comparative levels of exposure to SHS at home and work among nonsmokers aged ⩾12 years. Data from National Health Examination Survey for 1999-2010 were analyzed to estimate exposure to SHS. Total number of subjects included in the study was 24,791. Those who self-reported not having used any tobacco products during the last five days were considered nonsmokers for the purpose of this study. Serum cotinine levels were used as the outcome variable to indicate the level of exposure to SHS. Adjusted serum cotinine levels for those with no exposure to SHS, exposure to SHS at work only, exposure to SHS at home only, and exposure to SHS at home and work were 0.047 (0.044-0.050)n g/mL, 0.055 (0.047-0.064) ng/mL, 0.522 (0.401-0.678) ng/mL, and 0.485 (0.280-0.0840) ng/mL respectively. Public efforts to reduce exposure to SHS at home should be strengthened.

Intraoperative blood loss is not a predictor of prognosis for pancreatic cancer

PURPOSE

The relationship between intraoperative blood loss (IBL) and prognosis has been reported for some types of cancer, but not for pancreatic cancer, which has one of the highest mortality rates of any cancer. We conducted this study to analyze the relationship between IBL and clinical outcome for patients undergoing radical surgery for pancreatic cancer.

METHODS

The subjects of this study were 144 patients who underwent curative pancreatectomy for invasive pancreatic cancer between 2002 and 2014. Clinicopathological characteristics were recorded and prognostic factors were identified by univariate and multivariate analyses.

RESULTS

Large IBL was significantly associated with advanced tumor stage, a long operation time, a large tumor, portal vein resection, and blood transfusion. According to univariate analysis, IBL was also significantly associated with overall survival (OS) and relapse-free survival (RFS); however, it was not an independent prognostic factor for OS and RFS in multivariate analysis. According to multivariate analysis, lymph node metastasis and R-status were independent prognostic factors for OS and RFS. A subgroup analysis of patients who received no blood transfusion showed similar results.

CONCLUSION

Minimizing IBL is very important; however, the present study found that positive lymph node metastasis and R-status were stronger independent prognostic factors for pancreatic cancer.

Metastases of pancreatic adenocarcinoma: A systematic review of literature and a new functional concept

INTRODUCTION

Pancreatic cancer, especially Pancreatic Adenocarcinoma, is still associated with a high mortality and morbidity for affected patients notwithstanding considerable progresses in diagnosis and both surgical pharmacological therapy. Despite metastases from colorectal, gastric and neuroendocrine primary tumor and their treatment are widely reported, the literature has been rarely investigated the impact of localization and numbers of pancreatic metastases. This study performed a systematic analysis of the most recent scientific literature on the natural history of Pancreatic Adenocarcinoma focusing attention on the role that the "M" parameter has on a possible prognostic stratification of these patients.

MATERIAL AND METHODS

PubMed and Science Direct databases were searched for relevant articles on these issue.

RESULTS

Initial database searches yielded 7231 studies from PubMed and 29101 from Science Direct. We evaluated 1031 eligible full text articles.

CONCLUSIONS

An updated insight into the world of Pancreatic Tumors might help physicians in better evaluating mechanisms of metastases, patients selection and survival and in programming appropriate interventions to modify the worst outcomes of advanced disease.

Risk of cancer in patients with cholecystitis: a nationwide population-based study

OBJECTIVE

The objective of this study was to evaluate the risk of cancer in patients diagnosed with cholecystitis and possible interactions between cholecystitis and cholecystectomy.

METHODS

A retrospective population-based cohort study was conducted among patients diagnosed with cholecystitis that were registered in the National Health Insurance Research Database in Taiwan between January 1, 2000 and December 31, 2010. Standardized incidence ratios (SIRs) were calculated to compare the incidence of cancer in these patients to that of the general population. Adjusted hazard ratios (HRs) were also calculated to investigate whether cholecystitis increased the risk for specific cancers.

RESULTS

During a median observation period of 5.4 years, 1541 cancers occurred in 20,431 patients with cholecystitis, yielding a SIR of 1.97 (95% confidence interval [CI], 1.88-2.07). A significantly greater risk of biliary tract cancer (adjusted HR 1.72; 95% CI, 1.08-2.75) was observed after adjusting for potential risk factors. In contrast, cholecystectomy was found to attenuate the cancer risk, with the reduction of adjusted HR from 2.34 (95% CI, 1.62-3.37) to 1.28 (95% CI, 0.76-2.14).

CONCLUSION

Cholecystitis is an independent risk factor to extrahepatic biliary tract cancers, whereas cholecystectomy can attenuate the cancer risk of cholecystitis.

Demographics, epidemiology, and inheritance of pancreatic ductal adenocarcinoma

Pancreatic cancer (PC) will affect 48,960 persons in the United States and will result in 40,560 deaths in 2015, according to the American Cancer Society. On a global basis, at least 337,000 persons will be diagnosed with PC. The incidence of PC has increased slightly in the United States, though worldwide cases are likely to increase substantially due to the influence of cigarette smoking, rising obesity and type II diabetes. The development of PC is related to a state of chronic inflammation and insulin resistance. Well-established environmental and personal risk factors for PC include advancing age, cigarette smoking, second-hand tobacco smoke exposure, obesity, inherited familial cancer syndromes, Ashkenazi Jewish heritage, chronic pancreatitis, dietary factors, and diabetes. Other identified associations are human immunodeficiency virus infection, ABO blood group polymorphisms, hepatitis B virus, and Helicobacter pylori.

Exploration of the value of MRCP combined with tumor marker CA19-9 in the diagnosis of pancreatic cancer

This paper aims to provide an effective, accurate, and specific diagnostic method for the diagnosis of pancreatic cancer. It discusses the diagnostic value of magnetic res retrograde cholangiopancreatography (MRCP) combined with the detection of tumor marker carbohydrate antigen 19-9 (CA19-9) for pancreatic cancer. A group of confirmed cases of pancreatic cancer in some hospitals were randomly selected and subjected to an MRCP examination as well as serological CA19-9 detection. In addition, a group of patients whose pancreatic cancer was confirmed by surgery and pathology, and who underwent MRCP without the detection of the tumor marker CA19-9, were also selected for research. The experiment found that the rate of accuracy for the group that underwent MRCP combined with CA19-9 detection showed a higher positive value in the diagnosis of pancreatic cancer than in the group that underwent MRCP alone. Therefore, this paper proposes that MRCP combined with CA19-9 detection can be taken as the reliable and effective means for diagnosis of pancreatic cancer.

Fat, epigenome and pancreatic diseases. Interplay and common pathways from a toxic and obesogenic environment

The worldwide obesity epidemic is paralleled by a rise in the incidence of pancreatic disorders ranging from "fatty" pancreas to pancreatitis and cancer. Body fat accumulation and pancreatic dysfunctions have common pathways, mainly acting through insulin resistance and low-grade inflammation, frequently mediated by the epigenome. These mechanisms are affected by lifestyle and by the toxic effects of fat and pollutants. An early origin is common, starting in pediatric age or during the fetal life in response to nutritional factors, endocrine disruptor chemicals (EDCs) or parental exposure to toxics. A "fatty pancreas" is frequent in obese and is able to induce pancreatic damage. The fat is a target of EDCs and of the cytotoxic/mutagenic effects of heavy metals, and is the site of bioaccumulation of lipophilic and persistent pollutants related with insulin resistance and able to promote pancreatic cancer. Increased Body Mass Index (BMI) can act as independent risk factor for a more severe course of acute pancreatitis and obesity is also a well-known risk factor for pancreatic cancer, that is related with BMI, insulin resistance, and duration of exposure to the toxic effects of fat and/or of environmental pollutants. All these mechanisms involve gene-environment interactions through epigenetic factors, and might be manipulated by primary prevention measures. Further studies are needed, pointing to better assess the interplays of modifiable factors on both obesity and pancreatic diseases, and to verify the efficacy of primary prevention strategies involving lifestyle and environmental exposure to toxics.

Serum cytokine profile in patients with pancreatic cancer

OBJECTIVE

Pancreatic ductal adenocarcinoma is a deadly disease because of late diagnosis and chemoresistance. We aimed to find a panel of serum cytokines representing diagnostic and predictive biomarkers for pancreatic cancer.

METHODS

A cytokine antibody array was performed to simultaneously identify 507 cytokines in sera of patients with pancreatic cancer and healthy controls. The nonparametric Mann-Whitney U test was used to pairwise compare the controls, the pretreated patients, and the posttreated patients. Fold changes greater than or equal to 1.5 or less than or equal to 1/1.5 were considered significant. Receiver operating characteristic curves were used to assess the performance of the model. A leave-one-out cross-validation was used for estimating prediction error.

RESULTS

Comparing the sera of pretreated patients against the control samples, the cytokines fibroblast growth factor 10 (FGF-10/keratinocyte growth factor-2 (KGF-2), chemokine (C-X-C motif) ligand 11 interferon inducible T cell alpha chemokine (I-TAC)/chemokine [C-X-C motif] ligand 11 (CXCL11), oncostatin M (OSM), osteoactivin/glycoprotein nonmetastatic melanoma protein B, and stem cell factor (SCF) were found significantly overexpressed. Besides, the cytokines CD30 ligand/tumor necrosis factor superfamily, member 8 (TNFSF8), chordin-like 2, FGF-10/KGF-2, growth/differentiation factor 15, I-TAC/CXCL11, OSM, and SCF were differentially expressed in response to treatment.

CONCLUSIONS

We propose a role for FGF-10/KGF-2, I-TAC/CXCL11, OSM, osteoactivin/glycoprotein nonmetastatic melanoma protein B, and SCF as novel diagnostic biomarkers. CD30 ligand/TNFSF8, chordin-like 2, FGF-10/KGF-2, growth/differentiation factor 15, I-TAC/CXCL11, OSM, and SCF might represent as predictive biomarkers for gemcitabine and erlotinib response of patients with pancreatic cancer.

Pancreatic ductal adenocarcinoma: Risk factors, screening, and early detection

Pancreatic cancer is the fourth most common cause of cancer-related deaths in the United States, with over 38000 deaths in 2013. The opportunity to detect pancreatic cancer while it is still curable is dependent on our ability to identify and screen high-risk populations before their symptoms arise. Risk factors for developing pancreatic cancer include multiple genetic syndromes as well as modifiable risk factors. Genetic conditions include hereditary breast and ovarian cancer syndrome, Lynch Syndrome, familial adenomatous polyposis, Peutz-Jeghers Syndrome, familial atypical multiple mole melanoma syndrome, hereditary pancreatitis, cystic fibrosis, and ataxia-telangiectasia; having a genetic predisposition can raise the risk of developing pancreatic cancer up to 132-fold over the general population. Modifiable risk factors, which include tobacco exposure, alcohol use, chronic pancreatitis, diet, obesity, diabetes mellitus, as well as certain abdominal surgeries and infections, have also been shown to increase the risk of pancreatic cancer development. Several large-volume centers have initiated such screening protocols, and consensus-based guidelines for screening high-risk groups have recently been published. The focus of this review will be both the genetic and modifiable risk factors implicated in pancreatic cancer, as well as a review of screening strategies and their diagnostic yields.

Acid-base transport in pancreatic cancer: molecular mechanisms and clinical potential

Solid tumors are characterized by a microenvironment that is highly acidic, while intracellular pH (pHi) is normal or even elevated. This is the result of elevated metabolic rates in the highly proliferative cancer cells, in conjunction with often greatly increased rates of net cellular acid extrusion. Studies in various cancers have suggested that while the acid extrusion mechanisms employed are generally the same as those in healthy cells, the specific transporters upregulated vary with the cancer type. The main such transporters include Na(+)/H(+) exchangers, various HCO3(-) transporters, H(+) pumps, and lactate-H(+) cotransporters. The mechanisms leading to their dysregulation in cancer are incompletely understood but include changes in transporter expression levels, trafficking and membrane localization, and posttranslational modifications. In turn, accumulating evidence has revealed that in addition to supporting their elevated metabolic rate, their increased acid efflux capacity endows the cancer cells with increased capacity for invasiveness, proliferation, and chemotherapy resistance. The pancreatic duct exhibits an enormous capacity for acid-base transport, rendering pHi dysregulation a potentially very important topic in pancreatic ductal adenocarcinoma (PDAC). PDAC - accounting for about 90% of all pancreatic cancers - has one of the highest cancer mortality rates known, and new diagnostic and treatment options are highly needed. However, very little is known about whether pH regulation is altered in PDAC and, if so, the possible role of this in cancer development. Here, we review current models for pancreatic acid-base transport and pH homeostasis and summarize current views on acid-base dysregulation in cancer, focusing where possible on the few studies to date in PDAC. Finally, we present new data-mining analyses of acid-base transporter expression changes in PDAC and discuss essential directions for future work.

Ectopic fat storage in the pancreas using 1H-MRS: importance of diabetic status and modulation with bariatric surgery-induced weight loss

OBJECTIVES

Recent literature suggests that ectopic fat deposition in the pancreas may contribute to endocrine and exocrine organ dysfunction, such as type 2 diabetes (T2D), pancreatitis or pancreatic cancer. The aim of this study was to determine factors associated with pancreatic triglyceride content (PTGC), and to investigate the impact of bariatric surgery on ectopic fat pads, pancreatic fat (PTGC) and hepatic fat (HTGC).

SUBJECTS

In all, 45 subjects (13 lean, 13 obese nondiabetics and 19 T2D, matched for age and gender) underwent 1H-magnetic resonance spectroscopy, computed tomography of the visceral abdominal fat, metabolic and lipidomic analysis, including insulin-resistance homeostasis model assessment (HOMA-IR), insulin-secretion homeostasis model assessment (HOMA-B) and plasma fatty-acid composition. Twenty obese subjects were reassessed 6 months after the bariatric surgery.

RESULTS

PTGC was significantly higher in type 2 diabetic subjects (23.8±3.2%) compared with obese (14.0±3.3; P=0.03) and lean subjects (7.5±0.9%; P=0.0002). PTGC remained significantly associated with T2D after adjusting for age and sex (β=0.47; P=0.004) or even after adjusting for waist circumference, triglycerides and HOMA-IR (β=0.32; P=0.04). T2D, C18:1n-9 (oleic acid), uric acid, triglycerides and plasminogen activator inhibitor-1 were the five more important parameters involved in PTGC prediction (explained 80% of PTGC variance). Bariatric surgery induced a huge reduction of both HTGC (-51.2±7.9%) and PTGC (-43.8±7.0%) reaching lean levels, whereas body mass index remained greatly elevated. An improvement of insulin resistance HOMA-IR and no change in HOMA-B were observed after bariatric surgery. The PTGC or HTGC losses were not correlated, suggesting tissue-specific mobilization of these ectopic fat stores.

CONCLUSION

Pancreatic fat increased with T2D and drastically decreased after the bariatric surgery. This suggests that decreased PTGC may contribute to improved beta cell function seen after the bariatric surgery. Further, long-term interventional studies are warranted to examine this hypothesis and to determine the degree to which ectopic fat mobilization may mediate the improvement in endocrine and exocrine pancreatic functions.

Case-control study of aspirin use and risk of pancreatic cancer

BACKGROUND

Pancreas-cancer prognosis is dismal, with 5-year survival less than 5%. Significant relationships between aspirin use and decreased pancreas-cancer incidence and mortality have been shown in four of 13 studies.

METHODS

To evaluate further a possible association between aspirin use and risk of pancreatic cancer, we used data from a population-based Connecticut study conducted from January 2005 to August 2009, of 362 pancreas-cancer cases frequency matched to 690 randomly sampled controls.

RESULTS

Overall, regular use of aspirin was associated with reduced risk of pancreatic cancer [odds ratio (OR), 0.52; 95% confidence interval (CI), 0.39-0.69]. Increments of decreasing risk of pancreatic cancer were observed for each year of low-dose or regular-dose aspirin use (OR, 0.94; 95% CI, 0.91-0.98 and OR, 0.98; 95% CI, 0.96-1.01, respectively) and for increasing years in the past that low-dose or regular-dose aspirin use had started (OR, 0.95; 95% CI, 0.92-0.99 and OR, 0.98; 95% CI, 0.96-1.00, respectively). Reduced risk of pancreatic cancer was seen in most categories of calendar time period of aspirin use, for both low-dose aspirin and regular-dose aspirin use. Relative to continuing use at the time of interview, termination of aspirin use within 2 years of interview was associated with increased risk of pancreatic cancer (OR, 3.24; 95% CI, 1.58-6.65).

CONCLUSIONS

Our results provide some support that a daily aspirin regimen may reduce risk of developing pancreatic cancer.

IMPACT

Long-term aspirin use has benefits for both cardiovascular disease and cancer, but appreciable bleeding complications that necessitate risk-benefit analysis for individual applications.

Expression of microRNA-15b and the glycosyltransferase GCNT3 correlates with antitumor efficacy of Rosemary diterpenes in colon and pancreatic cancer

Colorectal and pancreatic cancers remain important contributors to cancer mortality burden and, therefore, new therapeutic approaches are urgently needed. Rosemary (Rosmarinus officinalis L.) extracts and its components have been reported as natural potent antiproliferative agents against cancer cells. However, to potentially apply rosemary as a complementary approach for cancer therapy, additional information regarding the most effective composition, its antitumor effect in vivo and its main molecular mediators is still needed. In this work, five carnosic acid-rich supercritical rosemary extracts with different chemical compositions have been assayed for their antitumor activity both in vivo (in nude mice) and in vitro against colon and pancreatic cancer cells. We found that the antitumor effect of carnosic acid together with carnosol was higher than the sum of their effects separately, which supports the use of the rosemary extract as a whole. In addition, gene and microRNA expression analyses have been performed to ascertain its antitumor mechanism, revealing that up-regulation of the metabolic-related gene GCNT3 and down-regulation of its potential epigenetic modulator miR-15b correlate with the antitumor effect of rosemary. Moreover, plasmatic miR-15b down-regulation was detected after in vivo treatment with rosemary. Our results support the use of carnosic acid-rich rosemary extract as a complementary approach in colon and pancreatic cancer and indicate that GCNT3 expression may be involved in its antitumor mechanism and that miR-15b might be used as a non-invasive biomarker to monitor rosemary anticancer effect.

Prognostic significance of SUVmax and serum carbohydrate antigen 19-9 in pancreatic cancer

AIM: To investigate the prognostic significance of pretreatment standardized maximum uptake value (SUVmax) and serum carbohydrate antigen (CA)19-9 in pancreatic cancer.

METHODS: From January 2007 to October 2011, 80 consecutive patients with pancreatic cancer who received positron emission/computed tomography before any treatment were enrolled in this study. The pretreatment SUVmax and CA19-9 level of the primary pancreatic tumor were obtained and compared with clinicopathological and prognostic factors. Student’s t test for unpaired data was used to analyze the differences between two groups. Univariate analysis and Cox proportional hazards regression were used to examine the independent effects of each significant variable. Survival was analyzed by the Kaplan-Meier method.

RESULTS: There was a significant correlation between both the SUVmax and serum CA19-9 of pancreatic cancer and R0 surgical resection (P = 0.043 and P = 0.007). Lymph node metastasis was associated with SUVmax (P = 0.017), but not serum CA19-9 (P = 0.172). On the contrary, the tumor stage was significantly related to serum CA19-9 (P = 0.035), but not SUVmax (P = 0.110). The univariate analysis showed that survival time was significantly related to tumor stage (P < 0.001), lymph node metastasis (P = 0.043), R0 surgical resection (P < 0.001), serum CA19-9 (P = 0.001), SUVmax (P < 0.001) and SUVmax plus CA19-9 (P = 0.002). Multivariate analysis clearly showed that only tumor stage (hazard ratio = 0.452; P = 0.020) was an independent prognostic factor for overall survival in pancreatic cancer. Higher SUVmax or CA19-9 showed worse prognosis. We found that high serum CA19-9 plus SUVmax was the most significant variable.

CONCLUSION: Higher pretreatment SUVmax and serum CA19-9 indicates poor prognosis. SUVmax plus serum CA19-9 is the most significant variable in predicting survival.

Pancreatic cancer, inflammation, and microbiome

Pancreatic cancer is one of the most lethal cancers worldwide. No effective screening methods exist, and available treatment modalities do not effectively treat the disease. Inflammatory conditions such as pancreatitis represent a well-known risk factor for pancreatic cancer development. Yet only in the past 2 decades has pancreatic cancer been recognized as an inflammation-driven cancer, and the precise mechanisms underlying the pathogenic role of inflammation are beginning to be explored in detail. A substantial amount of preclinical and clinical evidence suggests that bacteria are likely to influence this process by activating immune receptors and perpetuating cancer-associated inflammation. The recent explosion of investigations of the human microbiome have highlighted how perturbations of commensal bacterial populations can promote inflammation and promote disease processes, including carcinogenesis. The elucidation of the interplay between inflammation and microbiome in the context of pancreatic carcinogenesis will provide novel targets for intervention to prevent and treat pancreatic cancer more efficiently. Further studies toward this direction are urgently needed.

Nr5a2 maintains acinar cell differentiation and constrains oncogenic Kras-mediated pancreatic neoplastic initiation

OBJECTIVES

Emerging evidence from mouse models suggests that mutant Kras can drive the development of pancreatic ductal adenocarcinoma (PDA) precursors from acinar cells by enforcing ductal de-differentiation at the expense of acinar identity. Recently, human genome-wide association studies have identified NR5A2, a key regulator of acinar function, as a susceptibility locus for human PDA. We investigated the role of Nr5a2 in exocrine maintenance, regeneration and Kras driven neoplasia.

DESIGN

To investigate the function of Nr5a2 in the pancreas, we generated mice with conditional pancreatic Nr5a2 deletion (PdxCre(late); Nr5a2(c/c)). Using this model, we evaluated acinar differentiation, regeneration after caerulein pancreatitis and Kras driven pancreatic neoplasia in the setting of Nr5a2 deletion.

RESULTS

We show that Nr5a2 is not required for the development of the pancreatic acinar lineage but is important for maintenance of acinar identity. Nr5a2 deletion leads to destabilisation of the mature acinar differentiation state, acinar to ductal metaplasia and loss of regenerative capacity following acute caerulein pancreatitis. Loss of Nr5a2 also dramatically accelerates the development of oncogenic Kras driven acinar to ductal metaplasia and PDA precursor lesions.

CONCLUSIONS

Nr5a2 is a key regulator of acinar plasticity. It is required for maintenance of acinar identity and re-establishing acinar fate during regeneration. Nr5a2 also constrains pancreatic neoplasia driven by oncogenic Kras, providing functional evidence supporting a potential role as a susceptibility gene for human PDA.

Cigarette smoking and pancreatic cancer risk: more to the story than just pack-years

PURPOSE

Cigarette smoking is an established risk factor for pancreatic adenocarcinoma. However, few studies have thoroughly investigated the effects of independent smoking dimensions (duration, intensity, cumulative dose and time since quitting) on risk estimates. We analysed data from the Queensland Pancreatic Cancer Study (QPCS), an Australian population-based case-control study, with the aim of determining which smoking component is primarily important to pancreatic cancer risk.

METHODS

Our study included 705 pancreatic cancer patients and 711 controls. Logistic regression and generalised additive logistic regression (for non-linear dose effects) were used to determine odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Compared to never-smokers, current smokers had an increased risk of pancreatic cancer (OR=3.4; 95% CI 2.4-5.0) after adjustment for age, sex, education, alcohol intake and birth country. Of the various smoking dimensions, smoking duration and time since quitting had a greater effect on OR estimates (OR 1.3; 95% CI 1.1-1.4 and OR 0.8; 95% CI 0.7-0.8) than smoking intensity (OR 1.1; 95% CI 0.9-1.2), once ever-smoking was accounted for.

CONCLUSIONS

This study confirms the association between cigarette smoking and pancreatic adenocarcinoma, and provides evidence to suggest that smoking pattern, in addition to dose effect, may affect disease risk.

High expression of interleukin-22 and its receptor predicts poor prognosis in pancreatic ductal adenocarcinoma

BACKGROUND

The cytokine interleukin-22 (IL-22) and its receptor are present in the tumor microenvironment. Their function in pancreatic ductal adenocarcinoma (PDAC) remains largely unknown. The goal of the present study was to measure the expression of IL-22 and IL-22R in PDAC and assess their relationship with clinicopathological features and prognosis.

METHODS

The expression of IL-22 and IL-22R was evaluated by immunohistochemistry in PDAC tissues from 57 patients and by Western blotting in six tumors and adjacent nontumor tissues. A statistical analysis was conducted to assess the relationship between levels of expression, clinicopathological factors, and overall survival. In addition, the relationship between the expression of IL-22 and IL-22R and invasion was assessed by Western blotting and transwell assay with the PDAC cell lines PANC1 and BxPC3.

RESULTS

Positive IL-22 staining was detected in PDAC tissues and adjacent nontumor tissues. Positive IL-22R staining was detected in PDAC cells. High expression of IL-22 and IL-22R correlated significantly with lymph node involvement. IL-22 increased the phosphorylation of signal transducer and activator of transcription3, the expression of matrix metalloproteinase 9, and the invasion in PANC1 and BxPC3 cells in vitro while silencing of IL-22R RNA caused opposite effects. Most importantly, overall survival was significantly poorer in patients with high expression of IL-22 and IL-22R than in those with low expression.

CONCLUSIONS

These findings reveal the positive role of IL-22 and IL-22R in invasion and metastasis in human PDAC. IL-22 and IL-22R may be suitable independent prognostic markers in PDAC.

Diabetes, insulin use, smoking, and pancreatic cancer mortality in Taiwan

The aim of the study was to evaluate the link between diabetes and pancreatic cancer (PC) mortality and the joint effect of smoking and insulin use on PC mortality. A total of 39,988 men and 46,909 women with type 2 diabetes, aged ≥25 years and recruited in 1995-1998, were followed to 2006 for PC mortality. Age-sex-specific mortality rate ratios for diabetic patients versus the general population were calculated. Cox regression was used to evaluate hazard ratios for PC mortality for covariates including age, sex, diabetes duration, body mass index, smoking, insulin use, and area of residence. The interaction and joint effect of smoking and insulin use were also evaluated. A total of 89 men and 63 women died of PC. The mortality rate ratios (95 % CI) showed a significantly higher risk in diabetic patients with a magnitude most remarkable at the youngest age: 1.51 (1.15, 1.98), 2.02 (1.35, 3.03), and 8.36 (5.39, 12.98) for ≥65, 55-64, and 25-54 years old, respectively, for men; and 1.16 (0.84, 1.59), 2.12 (1.39, 3.23) and 3.33 (1.14, 9.68), respectively, for women. In multivariable Cox regression analysis, only age was significantly predictive for PC mortality. Although smoking and insulin use might be associated with a 50 % higher risk when analyzed as individual risk factors, they did not reach statistical significance. The interaction term of smoking and insulin use was also not statistically significant in additional modeling. However, smoking and insulin use jointly increased the risk with an adjusted hazard ratio (95 % CI) of 3.04 (1.37, 6.73) when compared to patients who did not smoke and did not use insulin. Diabetic patients have a significantly higher risk of PC mortality. In patients with type 2 diabetes, smoking and insulin use may jointly increase the risk by threefold.

The impact of perioperative blood glucose levels on pancreatic cancer prognosis and surgical outcomes: an evidence-based review

Although diabetes mellitus (DM) and pancreatic cancer (PC) are intricately linked, a comprehensive review addressing the impact of DM on PC prognosis and surgical outcomes is lacking. PubMed search was performed (1980-2012) using keywords "pancreatic cancer", "diabetes mellitus", "glucose intolerance", "pancreatic resection", "prognosis", and "post-operative outcomes". The search results were analyzed to determine the strength of association between DM and PC and to assess the impact of DM on PC prognosis and postoperative outcomes. Thirty-one studies involving 38,777 patients were identified. Patients with non-insulin-dependent DM have 1.5-2 fold increased relative risk of developing PC. Non-insulin-dependent DM is identified in 25.7% of patients with PC compared to 10.4% age-matched controls (95% confidence interval, 1.5-4.7; P < 0.0001). Patients with PC are more likely to have a diagnosis of new-onset DM than age-matched controls (14.7% vs 2.7%; P < 0.0001). Patients with PC with DM have a significantly lower overall survival than those without DM (14.4 vs 21.7 months; P < 0.001). The presence of DM significantly increases overall postoperative complication rates (45.6% vs 35.6%; P < 0.008). Patients with new-onset non-insulin-dependent DM are at a higher risk of developing PC and have a worse long-term survival and a higher rate of postoperative complications.

The relationship between lymphatic vascular density and vascular endothelial growth factor A (VEGF-A) expression with clinical-pathological features and survival in pancreatic adenocarcinomas

BACKGROUND

Pancreatic cancer is a rare tumor with an extremely low survival rate. Its known risk factors include the chronic use of tobacco and excessive alcohol consumption and the presence of chronic inflammatory diseases, such as pancreatitis and type 2 diabetes. Angiogenesis and lymphangiogenesis, which have been the focus of recent research, are considered prognostic factors for cancer development. Knowing the angiogenic and lymphangiogenic profiles of a tumor may provide new insights for designing treatments according to the different properties of the tumor. The aim of this study was to evaluate the density of blood and lymphatic vessels, and the expression of VEGF-A, in pancreatic adenocarcinomas, as well as the relationship between blood and lymphatic vascular density and the prognostically important clinical-pathological features of pancreatic tumors.

METHODS

Paraffin blocks containing tumor samples from 100 patients who were diagnosed with pancreatic cancer between 1990 and 2010 were used to construct a tissue microarray. VEGF expression was assessed in these samples by immunohistochemistry. To assess the lymphatic and vascular properties of the tumors, 63 cases that contained sufficient material were sectioned routinely. The sections were then stained with the D2-40 antibody to identify the lymphatic vessels and with a CD34 antibody to identify the blood vessels. The vessels were counted individually with the Leica Application Suite v4 program. All statistical analyses were performed using SPSS 18.0 (Chicago, IL, USA) software, and p values ≤ 0.05 were considered significant.

RESULTS

In the Cox regression analysis, advanced age (p=0.03) and a history of type 2 diabetes (p=0.014) or chronic pancreatitis (p=0.02) were shown to be prognostic factors for pancreatic cancer. Blood vessel density (BVD) had no relationship with clinical-pathological features or death. Lymphatic vessel density (LVD) was inversely correlated with death (p=0.002), and by Kaplan-Meyer survival analysis, we found a significant association between low LVD (p=0.021), VEGF expression (p=0.023) and low patient survival.

CONCLUSIONS

Pancreatic carcinogenesis is related to a history of chronic inflammatory processes, such as type 2 diabetes and chronic pancreatitis. In pancreatic cancer development, lymphangiogenesis can be considered an early event that enables the dissemination of metastases. VEGF expression and low LVD can be considered as poor prognostic factors as tumors with this profile are fast growing and highly aggressive.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/5113892881028514.

CA 125 concentration in portal blood as a predictor of resectability in pancreatic tumor

AIM OF THE STUDY

Pancreatic cancer is one of the most frequent cancers in the world. Only 20% of patients seem to have disease confined to the pancreas, but in only every second case the tumor turns out to be resectable during surgery. Tumor markers may be a useful tool in differentiating benign from malignant pancreatic tumors and in clinical staging. The purpose of the study is to assess CA 125 utility as a predictor of resectability in pancreatic tumor.

MATERIAL AND METHODS

66 patients were operated on for pancreatic tumor between October 2010 and July 2012. CA 125 concentration was measured in peripheral and portal blood. 57 patients were diagnosed with malignant and 9 with inflammatory tumor. Seven patients had metastases to the liver. Radical surgery was performed in 34 patients.

RESULTS

Significantly higher CA 125 concentration in portal blood was found in the pancreatic cancer than in the inflammatory tumor group (36.5 ±99.6 vs. 16.4 ±26.5; p < 0.05). CA 125 concentration in peripheral blood and in portal blood as well of patients with malignant pancreatic tumors and with metastases to the liver was significantly higher than in the group without metastases (146.15 ±256.1 vs. 18.5 ±17.5; p < 0.01 and 147.5 ±261.2 vs. 19.7 ±24.3; p < 0.05, respectively). CA 125 values in the group without metastases to the liver and in the case of radical surgery were significantly higher in portal than in peripheral blood (19.7 ±24.3 vs. 18.5 ±17.5; p < 0.001 and 13.2 ±15.0 vs. 13.0 ±15.2; p < 0.001, respectively).

CONCLUSIONS

Determination of CA 125 concentration in peripheral blood and in portal blood as well might be a useful tool in differentiating between malignant and inflammatory pancreatic tumors and when decisions on surgery extensiveness are being made.

Blood group determinates incidence for pancreatic cancer in Germany

Background: Genetic risk factors for sporadic pancreatic cancer are largely unknown but actually under high exposure. Findings of correlations between the AB0 blood group system (Chromosome 9q34,1—q34,2) and the risk of pancreatic cancer (PC) in patients from Asia, America and south Europe have already been published. So far it is unclear, whether this correlation between blood group an PC incidence can be found in German patients as well.

Methods: One hundred and sixty-six patients who underwent a resection of PC were evaluated in a period between 2000 and 2010. Blood group reference distribution for the German population is given as: 0: 41%; A: 43%; B: 11%; AB: 5%; Rhesus positive: 85%; Rhesus negative: 15%. Analyses were done using the non-parametric Chi²-test (p-value two sided; SPSS 19.0).

Results: Median age was 62 (34–82) years. Gender: female 73/44%; male: 93/56%. Observed blood group proportions: 0: 43 (25.9%)/A: 94 (56.6%)/B: 16 (9.6%)/AB: 13 (7.8%)/Rhesus positive: 131 (78.9%)/negative: 35 (21.1%). We detected a significant difference to the German reference distribution of the AB0 system (Chi² 19.34, df 3, p < 0.001). Rhesus factor has no impact on AB0-distribution (Chi² 4.13, df 3, p = 0.25), but differs significantly from reference distribution—probably due to initial AB0-variation (Chi² 4.82, df 1, p = 0.028). The odds ratio for blood group A is 2.01 and for blood group 0 is 0.5.

Conclusions: The incidence of PC in the German cohort is highly associated with the AB0-system as well. More patients with blood group A suffer from PC (p < 0.001) whereas blood group 0 was less frequent in patients with PC (p < 0.001). Thus, our findings support the results from other non-German surveys. The causal trigger points of this carcinogenesis correlation are still not known.